Papeles del Psicólogo / Psychologist Papers, 2019 Vol. 40(3), pp.

211-216
Articles
https://doi.org/10.23923/pap.psicol2019.2894
http://www.papelesdelpsicologo.es
http://www.psychologistpapers.com

PROMOTION AND PREVENTION IN MENTAL HEALTH:

WELL-FOUNDED HOPE, FUTILE ILLUSION OR PSYCHOPATHOLOGIZING
CONTRABAND?
Félix Cova Solar, Pamela Grandón Fernández, Sandra Saldivia Borquez,
Carolina Inostroza Rovegno and Consuelo Novoa Rivera
Universidad de Concepción

La promoción y prevención en salud mental son crecientemente reconocidas como estrategias fundamentales. Se ha demostra-
do que programas promocionales y preventivos en esta área pueden ser efectivos. Existe la expectativa de que la disemi-
nación de estos programas pueda ayudar a disminuir la brecha entre necesidades de atención en salud mental y recursos
disponibles. Junto con describir estos antecedentes, este artículo analiza algunos desafíos centrales para que esta área pueda
tener el desarrollo esperado. Se plantea que si este desarrollo se realiza desde la lógica del modelo médico puede contribuir
a generar respuestas inadecuadas y, paradójicamente, a incrementar las necesidades de recursos en salud mental. Se analiza
el riesgo que implicaría el uso masivo y recurrente del tamizaje de trastornos mentales desde una concepción medicalizadora.
Se propone que el desarrollo de la promoción y prevención en salud mental es un desafío mayor y necesario pero que debe
atender a las advertencias de lo que se denomina prevención cuaternaria.
Palabras clave: Promoción-prevención-salud mental-prevención cuaternaria-tamizaje.

Promotion and prevention are increasingly recognized as essential strategies in mental health. It has been shown that promo-
tional and preventive programs in this area can be effective. It is expected that spreading these programs may help to de-
crease the gap between the assistance needs in mental health and the resources available. Besides describing this background,
this article analyzes some of the main challenges necessary to achieve the desired development in this area. It is considered
that, if this development is carried out based on the logic of the medical model, it may contribute to creating inappropriate an-
swers and, paradoxically, to increasing the need for resources in mental health. We analyze the risks involved in the massive
and recurrent use of mental disorder screening based on a medicalizing conception. Finally, we propose that developing pro-
motion and prevention in mental health is a great and necessary challenge, but it must take into consideration the warnings
arising from what is known as quaternary prevention.
Key words: Promotion-prevention-mental health-quaternary prevention-screening.

or several decades, the relevance of mental health pro- importance of “mental hygiene” in the mid-nineteenth century

F motion and prevention has been highlighted by experts

and by various institutions (Campion, Bhui, & Bhugra,
2012; NRC/IoM, 2009; WHO, 2004, 2005). Although these
approaches have not yet had a notable impact on the agendas
of health systems, they are increasingly gaining recognition
and, in some countries, significant initiatives can already be
seen (Bährer-Kohler & Carod-Artal, 2017). Historically, promo-
tion and prevention, in general, and mental health, specifically,
have not been priorities in the field of health, so this recognition
is doubly significant (Knifton & Quinn, 2013).
Although voices regarding the value of promotion and pre-
vention in mental health have always existed, and can be
traced, in modern-day language, to approaches such as the
(Ray, 1863), a number of factors have meant that these voices
have become more intense in recent years. One of these has
been the development of a mental health perspective of public
health. This perspective has shown that the mental health needs
of populations are enormous and that it is impossible, as well
as illogical, to address them based on the sole logic of treat-
ment and rehabilitation (Petersen, Barry, Lund, & Bhana,
2014). The expectation is, therefore, that promotional and pre-
ventive policies and programs can contribute to a greater well-
being and positive mental health (promotion), to avoiding the
development of mental health problems and disorders (primary
prevention), and to reducing the impact of the latter through
detection and early treatment (secondary prevention). Effective

Received: 10 November 2018 - Accepted: 14 February 2019

promotional and preventive programs would decrease the per-

Correspondence: Pamela Grandón Fernández, Facultad de

sonal and social cost of presenting mental health problems or

Ciencias Sociales, Departamento de Psicología, Universidad de

disorders and reduce the need for treatment and rehabilitation

Concepción. Email: pgrandon@udec.cl

(CIHI, 2011). Currently, even the countries with the highest in-
come and with the most resources to address mental health

125
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needs have huge gaps between the estimated needs for care
and support for people with mental health problems and disor-
ders, and the services available (Saraceno, 2014).
A second factor that is affecting the greater efforts in the re-
search and development of preventive and promotional policies
and programs in mental health is that it is currently possible to
counteract the historical skepticism regarding the effectiveness
of actions in this area with empirical findings (Arango et al. al.,
2018). For a decade or so, the reviews indicate the availability
of a wide range of empirically proven programs to implement
the prevention of mental disorders (Jeste & Bell, 2011; Saxena,
Jane-Llopis, & Hosman, 2006), all of which has done nothing
but increase (Greenberg & Riggs, 2015). Even the elusive con-
cepts of well-being and positive mental health have been oper-
ationalized, in some way, allowing the accumulation of
evidence of effective promotional strategies (Anderson & Llané-
Jopis, 2011; Patel, Fliher, Nakapota, & Malhotra, 2008).
However, an overly optimistic perspective on the challenges
still facing the field of mental health promotion and prevention
would be risky. The valuable and legitimate desire to achieve
greater efforts and resources in this area should not dispense
with the need for critical reflection. To contribute to this reflec-
tion, this article analyzes achievements, challenges, and risks in
the area, focusing on how certain conceptualizations can not
only limit its future development but also contribute to the fact
that, paradoxically, the expansion of promotion and prevention
in mental health promotes a greater medicalization of society,
in the negative sense of the term.
Prior to this reflection, clarification of the concept and termi-
nology is important. In this article, the terms mental health
problem and disorder are used according to the usual conven-
tions. The concept of mental health problem is imprecise and
less “technical”, but it has the merit of not substantiating the
phenomenon that it describes, and it makes clearer the impor-
tance of qualifying what is being talked about, stimulating
contextualized analyses. The opposite occurs with the concept
of mental disorder, which generates the illusion of alluding to
specific and well-defined phenomena. The concept of mental
disorder is difficult to separate from a biomedical conception
(López & Costa, 2012). From the perspective of the authors of
this article, breaking with the biomedical conception is one of
the most relevant challenges in mental health in general, and
specifically, in the area of promotion and prevention in the
area. For the same reason, in the article, although the term
mental disorder is used occasionally, we are conscious that it
is a very debatable concept and, perhaps, on the way to obso-
lescence. In fact, the critique of this concept is one of the foci
of the analysis presented.
RESEARCH IN MENTAL HEALTH PROMOTION AND
PREVENTION
The development of the field of mental health promotion and
prevention depends closely on the quality of the studies that
support it. Most of the research has been aimed at evaluating
126
PROMOTION AND PREVENTION IN MENTAL HEALTH
the efficacy of the programs. Many of these efficacy investiga-
tions have been carried out with relatively high methodological
standards (for example, randomized clinical trials), although
they often have limitations such as short follow-up periods and
the use of outcome measures that are highly dependent on the
subjectivity of the participants. Another limitation is that there
are few replications of efficacy studies by teams that are inde-
pendent of the authors of these programs (Greenberg & Riggs,
2015). In general, it has been possible to obtain evidence prov-
ing that, in various areas of mental health, well-designed pro-
grams can have some degree of efficacy: prevention of
depression, anxiety, eating disorders, substance abuse, aggres-
sion and behavior problems and disorders, child abuse, and
suicide; promotion of child development, and promotion of
quality of life in older adults (Barry, 2015; Patel et al., 2008;
NCR/IoM, 2009). Although the effect sizes of the best-estab-
lished programs are medium or low, their consequences could
be relevant at the population level (Ahern, Jones, Bakshis, &
Galea, 2008). The strongest evidence is related to preventive
programs of behavioral disorders in childhood (Scott, 2018).
In recent years, research has shifted from efficacy studies to
studies of effectiveness or dissemination (Marchand, Stice, Ro-
hde, & Becker, 2011). It is not clear that programs with positive
indicators of efficacy maintain them when they are executed in
“natural conditions” —studies of “effectiveness”— or when dis-
seminated widely (Spoth et al., 2013). Valuations of the cost-ef-
fectiveness of various programs are also being carried out, with
encouraging results, which suggest that some actions —for ex-
ample, preventive programs in childhood— have relatively fast
economic returns and others have long-term but equally posi-
tive returns (Knapp, McDaid, & Parsonage, 2011).
Despite the criticisms that exist regarding the way of concep-
tualizing and measuring mental disorders, today it is still con-
sidered that a limitation of many prevention studies in mental
health is that they do not show that programs are effective in
reducing the incidence of the disorders themselves but instead
show alternative measures (for example, reduction of sympto-
matology or risk factors). Demonstrating efficacy or effective-
ness at the level of the incidence of a mental disorder involves
the use of very large samples and the use of very long follow-
up periods (Cuijpers, 2003). However, it is debatable to what
extent this is an effectively relevant limitation of the investiga-
tions because it assumes that the diagnostic criteria for mental
disorders are valid, an issue that is increasingly debated
(Wakefield, 2016). On the other hand, it has been shown that
it is a mistake to think that the programs will have specific ef-
fects on each disorder, given that the same determinants can
give rise to different consequences and disorders; also, a par-
ticular mental health problem or disorder can have different
causes (equipotentiality and multifinality, respectively) (Toth, Pe-
trenko, Gravener-Davis, & Handley, 2016). Consequently, pro-
grams are likely to have broader effects than just reducing the
incidence of a particular type of disorder (Arango et al., 2018;
Cuijpers, 2011).
FÉLIX COVA SOLAR, PAMELA GRANDÓN FERNÁNDEZ, SANDRA SALDIVIA
BORQUEZ, CAROLINA INOSTROZA ROVEGNO AND CONSUELO NOVOA RIVERA
LEVELS OF ACTION IN MENTAL HEALTH PROMOTION AND
PREVENTION
Overcoming the skepticism regarding the possibilities of pro-
moting and preventing mental health through specific programs
has been a great achievement. Today there is the reverse risk:
that the complexity and multidimensionality of the factors that
are involved in the well-being and mental health of individuals
and societies are ignored and the potential of limited programs
is overstated. While all the documentation on the subject al-
ways starts by recognizing the multiplicity of factors, on differ-
ent levels, that affect the well-being and mental health of
people and societies, emphasizing the importance of consider-
ing macro-structural factors such as economic, social, and cul-
tural ones (Petersen et al., 2014), the truth is that most of the
programs seek to act, above all, at a microsocial and individ-
ual level. Taken in rigor, the concepts of prevention and, partic-
ularly of the promotion of well-being and mental health are
revolutionary, since they involve questioning the complete mod-
els of society and culture, inequitable and excluding social
structures, the ways of organizing life in large cities, or the
dominant social values centered on production and consump-
tion, for example. There is a risk that the social determinants of
well-being and mental health are considered only at a rhetori-
cal level and that it is understood that, in practice, promoting
mental health and well-being is only a task of public awareness
(for example, media campaigns), or of mere encouragement to
the development of capacities and competences at micro and
individual levels through specific programs (for example, indi-
vidual resilience development programs). All this may imply the
related risk of overloading the health sector, which is the sector
most involved in the subject, with expectations and roles that
surpass it (Saraceno, 2014), as well as the risk of repeating to
some degree, the experience of promoting healthy lifestyles in
the field of “physical” health, a model whose limitations have
already been recognized (Cockerham, 2005).
PROMOTION AND PREVENTION OF MENTAL HEALTH AND
MEDICALIZATION
The intense medicalization of contemporary societies has gen-
erated concern due to its negative and iatrogenic effects (Con-
rad, 2007). In this context, the concept of quaternary
prevention emerged, understood as actions aimed at avoiding
or mitigating the negative consequences of the excessive activi-
ty of the health system (Jamoulle, 2009). In the field of mental
health, quaternary prevention has as its main object psycholo-
gization, psychopathologization, and social psychiatrization,
the abuse of the psychopathological diagnosis, and the exces-
sive use of psychopharmacology, but also of psychotherapy
(Ortiz & Ibáñez, 2011). Until now, interest in the risks and pos-
sible iatrogenic effects of mental health promotion and preven-
tion has been limited, except in specific situations such as the
negative effects of “debriefing” in relation to the development
of post-traumatic stress disorder (McNally, Bryant, & Ehlers,
2003), certain psychoeducational programs in relation to psy-
Articles
choactive substances (Werch & Owen, 2002), or concern
about the risks of early psychosis prevention strategies through
the identification and treatment of so-called high-risk mental
states (Fonseca-Pedrero & Inchausti, 2018). It has rarely been
seen that mental health promotion and prevention can, de-
pending on how they are focused and conceived, contribute se-
verely to a culture of fear of mental problems and disorders, of
dissatisfaction with the non-achievement of pre-set standards,
stigmatization of all those that are identified as persons or
groups at risk, and to increase the dependence of people,
groups, and institutions on professional networks. For years
now it has been pointed out that the proliferation of diagnostic
categories in mental health is contributing to generating a “cul-
ture of deficit” (Gergen, 1996) and an increasing “sickness” of
all people (Frances & Paredes, 2014). Prevention and promo-
tion in mental health can also contribute to this phenomenon.
It is perhaps in relation to the use of screening to identify peo-
ple and groups at risk where these iatrogenic effects may be
potentially more visible. In this regard, it should be considered
that the installation of screening and early detection procedures
can be extended to a variety of areas, and, in fact, this is sug-
gested in the proposals of the teams working on the subject. A
recent review that includes the various screening and detection
options that can be implemented now or that are already being
implemented shows what could become a climate of continuous
surveillance: screening for family history of mental disorders;
screening for genetic variants associated with an increased risk
of neurocognitive and psychiatric phenotypes; postnatal de-
pression screening; screening and monitoring of development
trajectories; detection of delay or alterations in developmental
milestones; detection of chronic irritability, hyperactivity and
cognitive decline; detection of altered social behavior, insuffi-
cient school results, psychotic experiences; detection of cerebral
or blood biomarkers (Arango et al., 2018). The iatrogenic ef-
fects that a climate of hypervigilance can generate derived
from massive or indiscriminate use of screenings and early de-
tection procedures can be accentuated by other factors. On the
one hand, the current tools available in mental health screening
and early detection procedures generate a high frequency of
false positives and it is not foreseen that there will be others
that may involve substantive changes in this regard in the short
term (Horwitz & Wakefield, 2009). On the other hand, and
more substantively, screening to identify the risk of disorder
means that there is clarity about what a mental disorder is and
the implications it has to satisfy the diagnostic criteria of a dis-
order. However, this clarity does not exist.
PROMOTION AND PREVENTION IN MENTAL HEALTH AND
THE BIOMEDICAL MODEL
Traditionally, it has been thought that the actions of promo-
tion and prevention arise from overcoming the biomedical
model of health, but this is not completely accurate. Although
promotion tends to break conceptually more clearly with the
biomedical paradigm than prevention, it can also be included,
127
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depending on how it is conceived and implemented, within a
medicalizing logic. This can happen if promotion is understood
as the search for the maximization of health, well-being, and
the extension of life, without the considerations that nuance and
contextualize these aims (Pérez, 1999). On the other hand,
preventing the incidence of mental disorders is usually consid-
ered the main focus of prevention in mental health, making pre-
vention dependent on this construct that belongs to the
biomedical paradigm. Although it could be argued that even if
the concept of mental disorder can be sustained from a non-
biomedical paradigm, its habitual understanding is still based
on this paradigm. From this perspective, mental disorders are
understood as discrete and delimited categories of “abnormal”
or “dysfunctional” patterns of psychological suffering or mal-
adaptation. These entities, in practice, become analogue to
physical illnesses in the field of mental health. Given the impos-
sibility, to date, of distinguishing these entities according to
substantive criteria, descriptive diagnostic criteria have been
developed for each disorder, but it is assumed that each one
has a determined biological or psychological dysfunction at the
base. The centrality of this conception of mental disorders for
the dominant biomedical paradigm is what explains the enor-
mous effort that has been made to generate “official” lists of
mental disorders and the continuous renewal of diagnostic cri-
teria (Bentall, 2009). This attempt to conceptualize mental dis-
orders has been debated for a long time and is currently in
open crisis (Poland & Tekin, 2017). The reliability, and, more
importantly, the validity of the existing diagnostic systems and
different categories of disorders is in doubt. So far, the field of
prevention in mental health has given little account of this crisis.
It is not clear what is involved or what it means to satisfy the di-
agnostic criteria of a particular disorder. There is some evi-
dence that the diagnostic criteria do not differentiate between
normal responses of malaise and maladaptation, and respons-
es that it makes some sense to call psychopathological, which
generates overdiagnosis and extends the psychopathologiza-
tion of people. The criteria do not allow the differentiation be-
tween people who require mental health treatment and those
who do not need it, nor do they contribute to the prognosis re-
garding the difficulties that people present (Bentall, 2009;
Wakefield, 2016).
Preventing mental disorders, meaning reducing the incidence
of disorders according to current diagnostic criteria or interven-
ing is, therefore, a poorly defined objective. What is most seri-
ous is that, given the ubiquity of the mental disorders identified
based on the current diagnostic criteria, trying to prevent them,
particularly through screening programs and early detection,
will only increase the number of people who will be informed
that they are at risk and, instead of reducing the treatment
needs, will cause more people to be referred to specialized
treatment without necessarily needing it. And, equally as or
even more serious, what happens to people will be understood
through the lens of the disorder, which by definition involves
and invites us to identify dysfunctions in the psyche itself (or bi-
128
PROMOTION AND PREVENTION IN MENTAL HEALTH
ology), reducing the chances of understanding in a contextual-
ized way the problems that may be affecting them. Diagnostic
labels have known effects of labeling and stigmatization (and
self-labeling and self-stigmatization) that can be extended, by
way of screening people and groups identified as “at risk” of
certain mental health “disorders”. In this context, particularly
worrisome is the misuse that can be made of possible genetics-
based indicators that indicate the presence of a predisposition
to experience particular disorders, increasing biologicism in
understanding the mental health difficulties experienced by
people (Demkow & Wolanczyk, 2017).
CONCLUSIONS
The development of promotion and prevention is a key area
in promoting “global mental health” (Bährer-Kohler & Carod-
Artal, 2017). The advances in the field in recent decades show
its enormous potential. However, there are significant chal-
lenges and risks that must be addressed carefully. On the one
hand, research in the field must transcend the emphasis on the
study of the efficacy of programs implemented in highly con-
trolled situations to the study of programs in natural environ-
ments, and must, progressively, contribute to the development
of policies and programs that articulate in a real way the fac-
tors of macro, meso and micro levels that affect the well-being
and mental health of societies and people. This requires a
broad and ecological paradigm that is central to the future de-
velopment of mental health promotion and prevention (WHO,
2004, 2005).
Consequently, overcoming the biomedical model, which also
tends to dominate in the field of mental health promotion and
prevention, is a central challenge. As proposed by Saraceno
(2014), not every effort to reduce the gap between mental
health needs and resources is beneficial; if it is not accompa-
nied by a change of paradigm that separates mental health
from biomedical conceptions, the reduction of the gap will con-
sist in more people going to receive incomplete and/or inade-
quate treatments, particularly pharmacological ones, with
dubious positive impacts, except for the profits of pharmaceuti-
cal companies. Although the risks of medicalization in the re-
stricted sense of increased drug use are smaller in the field of
promotion and prevention than in treatment, they are still pre-
sent, and above all, there is the risk that the most diverse prob-
lems, and human diversity, will be interpreted based on the
logic of the search for present or potential existing disorders
that are “in the individual”.
In summary, it is essential to give continuity to the efforts
aimed at increasing the promotion of mental health and wellbe-
ing, and the prevention of mental problems and disorders, but
it is necessary for this to be accompanied by a review of how
and where the valuable developments that have occurred in this
field can continue.
CONFLICT OF INTERESTS
There is no conflict of interest.
FÉLIX COVA SOLAR, PAMELA GRANDÓN FERNÁNDEZ, SANDRA SALDIVIA
BORQUEZ, CAROLINA INOSTROZA ROVEGNO AND CONSUELO NOVOA RIVERA
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